Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)

76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 2

WINNER NHS
NHS Improvement

Delivering major breast
surgery safely as a day case
or one night stay
(excluding reconstruction)


NHS
ASSOCIATION OF NHS Improvement
BREAST SURGERY

Day case or one night stay breast
surgical pathway (excluding reconstruction)

Primary care Pre-operative assessment Anaesthetics/surgery Post surgery follow-up options
optimising pre- • Overnight booking the exception not the rule • Anaesthetics: short • No follow up required
operative health • Full clinical and risk assessment eg venous thromboembolism acting, use local • Patient activated e.g. telephone
• Blood pressure prophylaxis anaesthetic call/questionnaire
• BMI, diabetes etc. • Anaesthetic/co-morbidity management seek prompt specialist • Analgesia: non • Pro-active follow up call
• Lifestyle advice advice steroidal/non opiate • Outpatients appointment
• Patient choice • Patient education: e.g. mobility - physiotherapist/nurse/DVD • Minimal intra operative • GP follow-up
• Patient information • Prosthesis advice fluids • Open access: seromas/drain
• Prescribe TTO’s • Sentinel Node Biopsy* management and complications
• Check patient informed surgical consent • Drains the exception not • Joint clinic: e.g. further treatment
• Inform patient of admission time, length of stay and discharge the norm options; chemotherapy/radiotherapy
date and time • Palliative care
• Plan theatre scheduling and timing

General Diagnosis & Continuing
Practitioner Assessment care for cancer
(80% of referrals) (Same day one stop MDT
/two visit system) Admission Post-operative patients
Referral
(2 week
Routine wait)
screening and Pre-operative Intra-operative Surgical
MDT
assessment Follow-up
(20% of referrals)

Diagnosis Admission (Day Unit, Treatment Centre, Post-operative Continuing care for
• Full clinical assessment Surgical Ward) • Analgesia: avoid PCA/opiates cancer patients
• Imaging: Mammogram/ultrasound/ +/-MRI +Chest X-ray • Admit day of surgery • Provide nutrition and mobilise • Continuing cancer care
• Pathology: Core/fine needle biopsy • Starvation – the ‘2 and 6’ rule fasting • Nurse led discharge assessment care plan
• Bloods time 6 hours for food and clear fluids 2 • Patient and GP discharge summary with 24 (including referral as
• Discuss informed consent hours prior to surgery hour contacts and wound care advise appropriate to AHPs)
• Pathology reporting • Consider carbohydrate drink) • GP discharge summary • Education – self
Outcomes • No pre med • Drain management information (if required) care management
• Discuss results • Pre-op analgesia (paracetamol/non • Fit prosthesis programme
• Involve patient in choice of treatments/trials/reconstruction steroidals) • Dispense TTO’s • Palliative care
• Obtain patient informed surgical consent
• Confirm treatment/surgery date ** Pre-operative assessment
• Provide patient information prescription, hand held *Intra-operative - Sentinel Node Biopsy Analysis: This is an emerging technique and needs to be evaluated.
record/care plan/patient diary
• Inform patient of next steps
• Inform GP positive results within 24 hours/negative within
10 working days

Patient informed decision making

Acknowledgements
NHS Improvement would like to thank the thirteen clinical spread networks, the British Association of Day
Surgery, the Association of Breast Surgery, Breakthrough Breast Cancer, clinical advisors and patients for
their support.


Delivering major breast surgery safely as a day case or one night stay 3

Contents

Foreword 4

Why should major breast surgery be an inpatient procedure? 5

From testing to spread... the approach 7

Keep improvement simple 8

Influences, innovation and incentives for spread 9

Transforming Inpatients Framework for Spread application
in practice:

1. Collaboration, partnerships and team working 11

2. Learning and unlearning 12

3. Continuous monitoring: Measuring spread and adoption 15

4. Patient centred 19

5. Spread simple principles and messages 21

6. Alignment with opportunities and levers 23

7. Leadership, engagement and accountability 26

Summary 27

References 28

www.improvement.nhs.uk/cancer


4 Delivering major breast surgery safely as a day case or one night stay

Foreword

Twenty five years ago, I am delighted to have the
when I was first a opportunity to introduce
consultant medical this work that
oncologist specialising in demonstrates the
breast cancer, patients effectiveness of providing
undergoing breast surgery major breast surgery as a
(mastectomy or breast day case or one night stay
conserving surgery) typically procedure.
stayed in hospital for 10
days. Within a few years This programme is a very
this had fallen to five days, successful demonstration of
but that then became the norm. developing and spreading a new way of working that
meets patients’ expectations and reduces the demand on
Much more recently a second revolution in surgical care in-patient beds at the same time in a safe and effective
has taken place. It is now recognised that the vast manner.
majority of operations for breast cancer (excluding
operations for breast construction) can be safely Many patients who need breast surgery are
undertaken as a day case procedure or with a single understandably anxious about their diagnosis, and this
overnight stay. has often been compounded historically by the need to
spend several nights in hospital, away from their families.
NHS Improvement has been working with clinical teams This NHS Improvement work has been able to change
across England to transform the way in which breast the way in which such patients are managed, and reduce
surgery is delivered. This work has been supported by the ‘medicalisation’ of their care, so that many feel that
the British Association of Day Surgery, the Association of they are able to retain their autonomy and get through
Breast Surgery and by patients. All the partners have the process of health care more easily.
recognised that the transformation is good for patients
and good for the NHS. Patients do not need to be It is a clear advantage, in the current extremely tight
admitted to hospital the night before surgery. Equally economic environment, that this change benefits
they want to return to normal life as quickly as possible. patients, is also to the benefit of those managing the
healthcare budget since it reduces the demand for in-
The original hypothesis underlying this work was that patient beds for a large cohort of patients and thus saves
streamlining could reduce length of stay by 50% and money for trusts.
release 25% of unnecessary bed days for 80% of major
breast surgery (excluding reconstruction). This goal has The day case and one night stay breast surgery
been exceeded. Mean length of stay has reduced form programme was started in a small area and has spread,
2.35 days to 1.35 days overall. The number of patients via NHS Improvement methodology, to hospitals across
with length of stay greater than one day has been the country. It has now been taken up by others beyond
reduced markedly. Overall bed days have been reduced the programme as well, resulting in a significant shift in
by more than 40%. national figures for length of stay for patients having
breast surgery.
Although improvements have been observed in most
NHS Trusts, significant reductions in lengths of stay could This is a quality improvement that helps patients and
still be achieved in some areas. I urge them to read this healthcare organisations; its very pleasing to think that
report and to take action. Meanwhile I would like to many patients who have to have breast surgery will be
thank all those who have delivered both quality and going “Home for Tea”!
productivity – a remarkable example of ‘QIPP’ in action.

Professor Sir Mike Richards Celia Ingham Clark
National Clinical Director for Cancer National Clinical Lead for
and End of Life Care Transforming Inpatient Care

www.improvement.nhs.uk



Why should major breast surgery
be an inpatient procedure?

• It’s a relatively short operation
• Low post operative pain Figure 1: The increasing shift to day case and one night stay has been gradual
• Patients can mobilise, eat and Breast Surgery Patients - Elective Procedures
drink early 60,000
• Rare post operative events
• Patients want to return to 50,000
normal life as quickly as
Number of Procedures

possible. 40,000

In 2007, NHS Improvement 30,000

Transforming Inpatient Care
20,000
Programme as part of the Cancer
Reform Strategy (2007) and recently 10,000
the Improving Cancer Outcomes
Strategy (2011) redesigned the breast 0
care surgical pathway (excluding Year Year Year Year Year
06/07 07/08 08/09 09/10 10/11 V13
reconstruction) with the working
No. of inpatient No. of inpatient No. of day cases
hypothesis that: admissions LoS >1 admissions LoS = 0,1

“Streamlining of the
breast surgical pathway • There has been a gradual shift in the • A further 30% have LOS of one
could reduce length of overall length of stay for patients night only, (2010/11 HES
(Figure 1). The traditional inpatient provisional)
stay by 50% and release pathway had a range of length of • The overall mean LOS has reduced
25% of unnecessary bed stay from 0-7 days (2007, Hospital by 56%, exceeding the original
Episode Statistics (HES) working hypothesis (Figure 2).
days for 80% of major • Currently (2011) around 42% of
breast surgery (excluding breast surgical procedures have
length of stay (LOS) = 0 days and a
reconstruction).”
‘day case’ ranging from 6 to 12
hours
Good progress has been made
• 72% of breast surgery patients
across England now benefit from
the pathway, this number Figure 2: Breast surgery patients - Elective mean length of stay
continues to increase indicating
3.5
that 85% is achievable, 3.15
exceeding the original 3.0
2.78
hypothesis. 2.57
Mean Length of Stay

2.5
2.33
2.35 2.04 2.03
2.0
1.61
1.81
1.5
1.33
1.0

0.5
Figures 1, 2 and 3 source: Transforming
Inpatient Care – HES Breast Surgery Patients, 0
a paper for the National Transforming Year Year Year Year Year
06/07 07/08 08/09 09/10 10/11 V13
Inpatient Care Committee, Sep 2011, based
on HES extraction by NATCANSAT, and Mean LoS - Inpatients only Mean LoS - Overall
analysis by DH. Further details on the HES
extraction are provided in appendix 1.




The continued spread, and
Figure 3: Breast surgery bed days reduced by 41%, exceeding sustainability of the breast surgical
the working hypothesis
pathway across England is an
Breast Surgery Patients - Elective Bed Days important contribution to the whole
140,000 cancer programme and as Professor Sir
Mike Richards states:
120,000

“Over the next 15 years
Number of Bed Days

100,000

80,000 the incidence of cancer
60,000 is likely to increase by
40,000
around 24% (based on
20,000
current trends). Putting
0
pressure on inpatients’
Year
06/07
Year
07/08
Year
08/09
Year
09/10
Year
10/11 V13
cancer services; hence in
Bed days for inpatient
admissions LoS >1
Bed days for inpatient
admissions LoS = 0,1
order to keep inpatients
costs at the same level the
average length of stay
must fall by one quarter.”
• Bed days for breast cancer have • Patient feedback of their experience
reduced from the baseline by 50,329 of the pathway is extremely positive Professor Sir Mike Richards (2011)
(41%) with most of the reduction • Strong clinical engagement is National Clinical Director for Cancer
due to shorter lengths of stay for evident in leading the improvements and End of Life Care
episodes longer than a day; • Variation in practice still remains
although the increase of short stays with 28% of breast surgical
(zero or one day) has contributed procedures staying in hospital longer If all patients with a length of
(Figure 3) than two days stay of more than one night
• The proportion of patients not being • Lengths of stay of more than one were converted to the day
admitted the day before surgery has night increases with age although
case/one night stay model,
increased from 69.6% (2006/7) to variation exists across Trusts
potentially 40,000 bed days
94.6% • Variation in clinical practice
could be saved.
• Professional endorsement of the surrounding the use of wound
pathway has been achieved drains, draining of, seromas, the
• A Best Practice Tariff (BPT) is administration of anaesthetics and
proposed for 2012/13 to incentivise pain control continues.
day case surgery




From testing to spread... the approach

Throughout the service improvement phases (Figure 4) NHS Improvement shared the learning across the NHS to encourage
local spread, adoption and adaption.

Figure 4: Service improvement stages

Phase Year Service Improvement stages NHS coverage Spreading the learning

1 2007 • Baseline the current situation
• Review clinical procedures
• Listen to all views and
perspectives
• Understand the culture, context
and content of Trusts, clinical
teams and pathways
• Identify best practice and
challenges

2 2008 • Testing out the idea: Proof of 7 NHS hospital sites The Winning Principles:
Principle – What could be Transforming Inpatient Care
achieved. The Winning (July 2008)
Principles (2008)
Meeting the Challenge Together
(October 2008)

3 2009 • Prototype testing the 25 NHS hospital sites Spreading the Winning Principles
transferability, confidence and and Good Practice (July 2009)
competence of the
improvement Consolidation Report (2009)
From Testing to Spread

4 2010-11 • Spread, adoption and adaption 13 clinical spread Spreading the Winning Principles
networks (72 hospital case studies (July 2010)
sites) 41% coverage
across England Breast day case/one night stay
case studies

Service improvement literature has, highlighted the multiplicity and complexity of service improvement, redesign the
challenges of spread and the time it takes…. it’s like a marathon not a sprint, however, it’s a race worth doing.

Pettigrew et al 1992, Senge 1999, Plesk 2000, Fraser 2002, McNulty et al 2002,
Ovretveit et al 2002, Williamson 2007, Driver 2008).




Keep improvement simple

Figure 5: A consistent systematic approach was applied to capture the impact and learning

Testing Cycles Is it the
Analysis Identify the Visioning Test out the ideas/ right solution
Baseline from real root of the What are you innovations to address the
different perspectives problem trying to achieve? Test confidence real problem
and competence NO

YES

Evaluate and Case for change Agree the Evaluation
Implementation Plan the implementation redesign and Evaluate the benefits
check Implement the of the test idea implentation of the What is the
sustainability idea Build the case for change improvements difference?

Clinical Spread Spread/Adoption
Networks Strategy Winning Principles
Capture the impact and learning

The redesign and streamlining of the breast surgical pathway took a simple systematic approach involving a multitude of
reiterative service improvement cycles (plan do study act) and building the evidence for continuous improvement (Figure 5).




Influences, innovation and incentives for spread

Over the four years common themes and practices have emerged that supported the spread of the breast pathway. The
themes have been collated and applied to the Transforming Inpatient Framework for Spread (Figure 6). The spread
framework identifies the common components found to influence the rate of spread.

Figure 6: Transforming Inpatient Framework for Spread - Common themes and practices

Spreading new ideas and good practice
Understanding what good practice looks like
Active dissemination Prove what works and the benefits
Passive diffusion Involve those who need to be actively
‘One size fits no one problem’ involved at the start

A Vision
for Quality
Improvement Systematic
Spread Receptive to the improvement
Improvement
Strategy Adaption to the context
Approach
Policies and procedures A degree of flexibility

Linked
Organisational
Strategic and
Culture
Operational
and Fit
Change

Continuous Spread Spread
Information Communication
Monitoring Simple
Shared comparative
Progress and Making the Principles and
Use of opinion leaders
data Connections Finding the right focus
Impact Messages
for quality and
efficiency

Collaboration Leadership
Partnerships Engagement
and Team Accountability
Working
Clinical and managerial
Stakeholders Alignment
Responsibility for delivery
Ownership and a Learning with
Executive leadership
distribution of & Unlearning Opportunities
responsibilities Patient and Levers
networking Centred

Knowledge required Local quality indicators and priorities
Coaching Commissioning agreement and healthy
Changing practice and behaviour competition
Patients involved in testing
Training
Accepted or rejected the improvement

The framework reflects the work of Pettigrew (1992) Receptive Contexts for Change and
Rodgers (2003) Theory on the Diffusions of Innovations.




All the components of the framework were relevant and applied. Seven components (Figure 7) appeared to be more
influential in enhancing spread within clinical teams. This was evident from local interactions, case studies and reported site
feedback involving clinical leadership, multidisciplinary teams and patients.

Figure 7: The seven influential components

A Vision
for Quality
Improvement Systematic
Spread
Improvement
Strategy
Approach

Linked
Organisational
Strategic and
Culture
Operational
and Fit
Change

Continuous Spread Spread
Monitoring Simple
Progress and Making the Principles and
Impact Connections Messages

Collaboration Leadership
Partnerships Engagement
and Team Accountability
Working

Alignment
Learning with
& Unlearning Opportunities
Patient and Levers
Centred




Learning from the 13 national clinical spread networks on the seven dominate
components - Transforming Inpatients Framework for Spread application in practice:

1. Collaboration, partnerships and team working

Getting teams “It's been very gratifying to have been able to share our
together was
extremely experiences with so many teams from around the
Collboration,
partnership
beneficial. country. I have been impressed with the interest and
Rodgers
and team (2003), enthusiasm of teams and the quality of the discussions,
working highlights which have helped us to further examine our practice
the
importance of and the perceptions around enhanced recovery after
the nature of the breast surgery.”
social system in which innovations are
diffused. The clinical spread networks Hamish Brown, Consultant Breast and General Surgeon, Sandwell and West Birmingham
were brought together as a Hospitals NHS Foundation Trust
community for spread involving
organisations, clinical and managerial
teams, patients and carers.

Their contribution to spread was Figure 8: National Clinical
invaluable through enhancing the Spread Networks
debate and sharing learning with
peers. They provided a succinctness
gaining consensus on the breast
pathway. The sites shared personal
experiences, perceptions and concerns.
They could be described as the “early Lancashire and
South Cumbria Humber and
majority” of adopters, forming a
Yorkshire
localised network for spread, Greater
communication and an important link Manchester
in the spread process with their Merseyside
deliberate willingness to adopt. and Cheshire Anglia

East Midlands

Pan
Birmingham
Arden

North
Three Counties
West
Avon, Somerset London
and Wiltshire

South West London

Thames Valley




Transforming Inpatients Framework for Spread application in practice

2. Learning and unlearning

Many lessons
have been
Supporting spread: Key learning from
learned over the clinical spread networks:
the four
Learning and years. The knowledge of 13
unlearning Some of
the learning
was new,
reiterative and Take a systematic Understand the national
challenging.
approach to service and local context and
It was evident across the sites that there improvement. This takes coherence with local
was variation in service improvement values and priorities.
understanding and application. Also, builds up a
time but
This should not be
the time required for redesign was a
challenge for many organisations. This
good evidence underestimated and is
can make the continuous spread of base and gets to the real needed to gain
improvement difficult. commitment to deliver in
root of the problem.
challenging times.

Give the right messages Engagement with key
in the right language to people leading change is
the different audiences and to not enough, support
spread the knowledge them to manage,
for persuasion and organise and mobilise
decisions.
the change.
Clinicians don’t like
targets, managers do, and
patients are more
concerned with
getting better. Build relationships
across professions and
Patient experience and organisational
feedback is a key factor in boundaries.
accelerating the pace
of spread. There is a need to create
the common purpose.




Keep things simple, Clinicians focus on Identifying key
realistic and flexible. research, gathering principles that can be
more evidence and adapted to benefit all
It’s ok to get it audit. patients develops a
wrong. common purpose.
They are often
uncomfortable with the
service improvement
approach – but once
they understand its
Understand the value there is no The breast pathway is
stopping them. common sense, simple
measurement of
and comprehensible.
impact and success and
Those that do not
be clear what you want understand are in the
to achieve, but remember minority but can be time-
one persons new idea is consuming. Go with the
another person’s normal majority – the others will
practice. catch on later.

The importance of Build the evidence base Professional boundaries
and traditional roles can be
communication, from the begining of the
improvement work to barriers to spread.
co-operation, and
collaboration in strengthen, spread We found the doctors
working partnerships is and sustain and to win accepted the pathway
vital and so is over the sceptics. quicker than the nurses, but
commitment. once the nurses came on
board it flew.




Some of the learning focused on ”There was a misconception that the proportion of
dealing with uncertainties,
assumptions and perceptions. Peer to women who would be suitable for early discharge in
peer support helped to build parts of the country with greatest concentration of
confidence levels in the new pathway
and the changes in clinical practice. elderly or socially deprived patients would be difficult.
The results have shown this not to be the case with
Four specific aspects were commonly achievements from Birmingham (the fourth most
highlighted:
deprived area in the country outside London) and Kings
1. Changing clinical practice College Hospital NHS Foundation Trust who has 20% of
relating to the use of wound
drains, drainage of seromas and patients who are asylum seekers and a high number of
pain control. patients with complex psychological support needs,
2. Assumptions that patients
with many from a socially deprived background. Day
would not want to go home surgery has been beneficial for sorting this out
earlier.
smoothly.”
3. Perceptions that the redesign
was a cost cutting exercise. Jo Marsden, Consultant Breast Surgeon, Kings College Hospital NHS Foundation Trust

4. Preconceptions “We do this
anyway” and “this will increase
Many of these uncertainties had been
re-admissions.”
tested by the early adopters (see
Figure 4 - Spreading the Learning).

“One must learn by doing The spread networks included some of
the thing, for though you the early adopter sites. Bringing these
together helped to decrease the
think you know it, you uncertainty and provide an evidence
have no certainty until base in which to build the new
knowledge and challenge the old.
you try.”
The spread networks could be
Sophocles, 400BC described as the early majority
adopters (Rodgers, 2003).





3. Continuous monitoring: Measuring spread and adoption

Measuring the Spread survey Relative advantage, complexity
spread and and trial: A four month national audit
adoption of NHS Improvement conducted a wider (November 2010 to March 2011);
Continuous completed by 61% of spread sites
the breast spread survey (2010): This identified
monitoring: pathway that there was an increasing uptake of provided important insights. Data was
Measuring spread cannot be NHS Trusts applying Winning Principle collected on 2,087 patients, 666
and adoption over 2 (NHS Improvement Transforming mastectomy patients, and 1,421 wide
simplified. Inpatient Winning principles 2009) local excision and other breast
It is ever- particularly associated with the breast procedures (cancer and non cancer).
changing and surgery pathway.
many measurement indicators only The purpose of the audit was
provide part of the story. Rodgers threefold; to measure progress
(2003) recommends that four towards compliance against the
attributes should be measured, but elements of the pathway, identify the
these rely on individual’s perceptions changes in practice and to capture the
as a measure of spread. views of patients who had
Winning Principle 2 experienced the new pathway.
Rodgers attributes include: All patients should be on defined
• Rate of adoption The audit incorporated areas identified
inpatient pathways based on their
• Complexity in the National Mastectomy Audit
tumour type and reasons for
• Relative advantage report 2010 and the national
admission.
• Trial. inpatient survey (2010).

These are well researched factors and Complexity: Local baseline of Breast pathway audit results
taken into account as part of the compliance with the elements of the
spread stage. breast surgical pathway were captured Wound drains
by the spread sites carrying out a The audit showed there continues to
Are these attributes a measure of pathway analysis reviewing their be clinical variation in the usage of
spread and adoption? current practice. wound drains and identified that
It was found that certainly the patient’s with wound drains required
attributes added to knowledge, 21% (Figure 9) more aspirations than
learning and communication but the patients without drains.
spread and adoption is “a marathon,
not a sprint”, as the breast
improvement work illustrates. It has Figure 9: Patients who had drains required 21% more aspirations
taken four years to reach this stage,
working with the majority of early 100
adopters. Although other Trusts 11.2%
90
outside of the spread networks have 32.2%
80
adopted the new pathway the
Percentage of Patients

70
evidence of this is based on HES
length of stay data. 60
50 88.8%
Application of Rodgers Attributes 40
67.8%
Influence Spread and Adoption
30

Rate of adoption: National HES data 20

provided the national picture and 10
benchmarking of progress, related to 0
No Drains Drains
the shift in length of stay, potential
number of bed days released and the No Aspiration Aspiration
trends.




The audit indicated a shift in practice:
• There was an increase in the number Figure 10: Length of stay increased for sixteen
patients as a result of having a drain
of patients not having wound drains
• Patients are now having drains 9
removed prior to discharge 8
• Patients are now being discharged
7
home on the day of surgery with
Number of Days

their drains in situ. 6
5
Traditionally, patients would have 4
remained in hospital until the drain 3
was removed. Results showed that the
2
impact on primary care of patients
1
going home with drains in situ has
been minimal. 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Number of Patients
The audit showed that only 31 patients
were reluctant to go home with drains
in situ. Sixteen patients stayed in
hospital between three days to eight
days until their drains had been Figure 11: 30% of patients said they did not require any analgesia
removed (Figure 10). Although the
450
numbers are small the impact on bed
days is significant. 400
Usage Number Recorded
from Network Analysis

350
Clinical teams are continuing to 300
conduct local audits associated with 250
wound drains, particularly looking at
200
the cosmetic effects when using drains
150
compared to no drains.
100
Pain control 50
• Pain control was a key feature of the 0
Paracetamol Ibuprofen Diclofenac Paracetamol,
audit. Concerns had been raised by Paracetamol Paracetamol Tramadol
patients and clinicians that reducing Codeine Cocodamol Dihydrocodeine Codeine,
Paracetamol Paracetamol Diclofenac,
length of stay relies on the patient Paracetamol
receiving adequate pain control. The Analgesia Drugs and Drug Combinations

audit found the majority of patients
pain was controlled with
paracetamol
• 30% of patients reported that “The centres that have successfully implemented 100%
although they had only been in
hospital as a day case or one night day case or one night stay mastectomy have combined
stay they had not needed to take either oral or intravenous paracetamol, often
any analgesia at home (Figure 11)
• The audit found that analgesia for commenced preoperatively, with one or more local
mastectomy should be multimodal. anaesthetic technique i.e. local infiltration, installation
Various combinations of paracetamol
plus one or more local anaesthetic
of local anaesthetic into the wound and/or peripheral
technique are able to provide nerve blockade.”
effective analgesia.
Martin Kuper, Consultant in Anaesthesia and Intensive Care Medicine, The Whittington
Hospital NHS Trust and NHS Improvement Enhanced Recovery National Clinical Lead




Arm and shoulder exercises
• The redesigned pathway introduced Figure 12: Patients who performed shoulder exercises
arm exercises prior to surgery in
600
contrast to traditionally
YES NO
post-operatively. Patients pre-
500
operatively received information and
Number of Patients
were shown exercises. The audit
400
found that 30% of patients
reported that they did not do any 300
arm exercises post discharge
(Figure 12). 200

100

0
Partial Excision Re-excision of Wire Guided Mastectomy
of Breast Breast Margins Partial Excision
of Breast

Re-admission rates
There was an assumption that reducing the length of stay would increase
re-admissions. The audit showed a 2% re-admission rate, which is below the
national average 3.2% (HES 2010), The main cause for re-admissions requiring
therapeutic intervention are shown in Figure 13.

Figure 13: Main causes for re-admission

Haematoma Mastectomy

Haematoma Other

Wound Dehiscence Mastectomy
Complication Type

Wound Dehiscence Other

Skin Necrosis Mastectomy

Skin Necrosis Other

Systemic Complications Mastectomy

Systemic Complications Other

0 1 2 3 4 5 6
Percentage of Patients




Length of stay - from days to hours
Figure 14: Shift from traditional inpatient to day case or one night stay
The audit established the length of Actual Length of Stay by Procedure Type
stay in hours, highlighting a shift in November 2010 - March 2011
practice as length of stay is 120
traditionally recorded in days. (Figure Other Breast Procedures
14) Importantly, this provided the 100
Number of Patients

evidence that the original definition Total Excision of Breast - Total Mastectomy NEC
80
of 23 hours was not accurate.
Variation in admission times and
60
theatre scheduling across the spread
networks needed to be taken into 40
consideration leading to the revised
definition, breast day case or one 20
night stay pathway.
0
0 8 15 23 30 37 46 53 60 70 77 84 101 108 124 132 149 174 195 271 529 8817
Delays in discharge
Length of Stay (Hours)
The audit highlighted that 10.5% of
patients had a delayed discharge, the
reasons recorded were:

• Patients did not want to go home
with a drain in situ
• No local drain policy re discharge
home with drains in situ
• No one at home and delayed social
care package, not noted
pre-operatively
• Changes in the initial extent of
surgery: Immediate reconstruction,
bilateral mastectomy
• Nausea
• Awaiting medical decision
• Other medical problems
• Booked as an inpatient!





4. Patient centred

One of the Patients have evaluated the new “Highly recommended -
strongest breast pathway positively
influences The patients’ experience has been day surgery is better.”
for spread captured in various ways:
Patient is the
centred Patients challenged professional
‘patient’s Patients have been recorded on film assumptions
voice.’ sharing their experiences: Nurses and doctors at Kings College
www.improvement.nhs.uk Hospital NHS Foundation Trust found
Patients patients were asking to go home.
were involved “I was in at 7am, sitting Raising the question why are we
in the redesign of the pathway and keeping patients in? Patients also
told us: up with tea and biscuits at asked to go home at Northampton
11am, home for tea by General Hospital NHS Trust, George
“Being diagnosed with 3pm and out dancing at a Eliot Hospital NHS Trust and Derby
Hospitals NHS Foundation Trust.
breast cancer can be a party on Saturday night.”
difficult transition to Frequently concerns were raised by
professionals particularly nurses that
make, one day you are a “Just because you are reducing the length of stay could lead
healthy person, the next older does not mean you to patients not receiving adequate
you are a patient with communication, information and
have to stay in hospital support. The audit of over 2,000
cancer.” longer.” patients (2010) who experienced the
new pathway indicated this not to be
Patients talked about how: the case (Figure 15). The results are
comparable with the National Patient
“Unnecessary waits, Survey (2010).

procedures and sitting
around in beds increased Figure 15: Audit of 2,000 patients who experienced the new pathway
anxiety.” (Four questions taken from the National Patient Survey, 2010)

Patient survey question Response
Patients stressed:
Q1 Were you involved as much as 92% Yes definitely
“We want to get back to you wanted to be in decisions (mastectomy and other
normal as soon as about your care and treatment? procedures)

possible.” Q2 How much information about 93% Right amount
your condition or treatment was (mastectomy)
“The new pathway should given to you? 94% Right amount (other
procedures)
value our time.”
Q3 Did you feel you were involved in 77% Yes definitely
decisions about your discharge (mastectomy)
“Treat me as a person not from hospital?
a cancer patient.”
Q4 Did hospital staff tell you who 83% yes definitely (other
to contact if you were worried procedures)
about your condition or 94% Yes (mastectomy & other
treatment after you left procedures)
hospital?




Independent patient evaluation Different patients views are a key factor to spread
Different strategies for patient engagement and involvelment were used
Patient focus groups were held as part across the spread networks (Figure 16).
as an independent qualitative study of
experiences of the pathway (Health
Experiences Research Group University Figure 16: Patient engagement strategies
of Oxford 2011). The 13 national
clinical networks were invited to Ask questions Patient voices
participate in the study by inviting their
patients to take part. Knowing patient Charities
expectations
What is informed Spread the message
choice?
What ideas should we
test?

Get feedback Pre and post operative focus groups
Post operative
Story boards and story telling
Telephone calls
Patient questionnaires
Audit change Patient videos

Patient diaries

Independent evaluation findings:

“Patients were often surprised that they could be
treated on a day case or one night basis. Some patients
and their friends and family, were initially suspicious
about whether the service was driven by a desire to cut
costs. Experiences in hospital (waiting for surgery,
communication and information, quality of care,
emotional support and discharge) were described
positively and acted to reassure patients that their care
would not suffer, despite short stays.

This positive experience was slightly undermined if
hospital staff appeared critical of short stay.“
(Barlow et al 2011)





5. Spread simple principles and messages

Patients traditionally stayed in hospital “More challenging was
for as long as six days, now the
majority are home the same day or convincing some of the
Spread simple The after one night. Patient’s challenged hospital staff that the day
principles and concept of professional beliefs of not wanting to
spread be in hospital. There was: case or one night stay
messages
networks as ambulatory care was
a forum of “Reluctance on the part achievable for patients
communication
has been key
of some staff to discharge having mastectomy and
to spread messages and make patients sooner and with axillary node clearance.
interpersonal links to influence others.
a drain.” However, confidence in
The success of the approach relates the process has grown
to its affiliation with the common Burton Hospital and Kings Mill Hospital
purpose; and a overcame the issue by holding substantially with
“group of knower’s.” education events for ward nurses and implementation and
feeding back patients positive
(Driver A, 2011) comments. successful outcomes.”
Concerns were raised about the Yeovil District Hospital (2011)
Interestingly, it was found that
although the spread networks were reduction in the length of stay being
detrimental to patients psychological/ Across the clinical spread networks,
geographically located, the informal
physical well being. The recent audit coversations about patient experience
networks across geographical areas
of patients (80% response) indicates and satisfaction highlighted that the
were often stronger, particularly with
that there has been no adverse effect, pathway was received positively.
clinicians.
but the foundation for this lies with
Through using simple messages which good pre-operative assessment and “Patient feedback has
informing patients that they will be
relayed information, principles and
going home on the day of surgery or
been extremely positive,
sharing practices on the ground
knowledge was enhanced and the following day right from the patients reported they
discussions and conversations beginning. (Clinical Networks 2010). were involved in their
were stimulated.
“Changes in clinical care, treatment and
“First of all we had to practice have had a discharge and received
overcome our own positive effect with other sufficient information.”
preconceptions of procedures, for example Southport and Ormskirk Hospital
patient’s opinion about a patients having a
NHS Trust (2011)

shorter stay in hospital. therapeutic mammoplasty,
We thought patients now also only have a
would find the shorter stay single night’s stay.”
unacceptable and patient
Geraldine Mitchell, Consultant Breast
anxiety levels would Surgeon, Royal Liverpool and Broadgreen
increase; but, we did not University Hospitals NHS Trust

find this to be the case.”
Royal Bolton NHS Foundation
Trust (2011)




Wider conversations Simple messages... hints and tips
Breast charities and patient groups
played an important contribution in
helping to spread the messages about For the health community For admission and discharge
the new pathway. It has been really • Increase dialogue across the • Staggered admission times are
encouraging to see patient’s reviews health community improves possible and reduced unnecessary
www.independent.cancerpatientsvoice working relationships with waits for patients
.org.uk primary care and provider • Nurses like nurse led discharge.
colleagues They have reported this increases
• Spread sites arranged training job satisfaction, skills base and
events for community staff and knowledge allowing them to
“We showed that not some planned GP site visits to manage their work load more
inform colleagues of the effectively
only is this pathway improvements • Pre-prescribed discharge
acceptable to the great • Review and share patient medication (TTOs) on admission
information with community and pre-packed TTO on the day
majority of patients but colleagues as early as possible unit/ward prevents discharge
that it is genuinely • Reassure GPs the new pathway delays
does not increase their workload • Consultants have said that the
preferred by them, and • Communicate to GPs, practice ward rounds are now able to
that this can be achieved nurses and district nurses that focus on patients requiring more
patients will be discharged home medical input and they have
without any compromise earlier and safely because they are achieved a reduction in length of
in the quality of care with better sooner stay without detriment to the
• The new pathway focuses on patient
patients feeling quality and safety not pushing • Patients are not left without
empowered to make patients through faster to save support: 24/7 cover and
money telephone advice/support lines
decisions and choices.” • The changes in anaesthetics have and follow-up support calls are
National Clinical Spread Networks allowed patients to recover more available to patients.
(2011) quickly following surgery
• The breast pathways aim is to ‘get
back to normal as soon as
possible’….”Home in time To access the recent success stories
for tea.” from across England on delivering
major breast surgery as a day case
or a one night stay (excluding
reconstruction) case studies and for
For pre-assessment further information please visit:
• Managing patient’s expectations www.improvement.nhs.uk/cancer
from the beginning has been key.
Patients need to be advised at the “It’s do-able, safe and
outset of their likely length of stay
which is reinforced by the whole patients want to
team throughout the pathway go home.”
• Physiotherapists and breast care
nurses see patients at pre- National Clinical Spread Networks
operative clinic providing earlier (2011)
support and risk management
• Pre-assessment is a vital part to
the success of the pathway.


Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)

Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)

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